Botanical Treatment Of Nausea And Vomiting Of Pregnancy And Hyperemesis Gravidarum

2011

According to Borrelli et al., the potential teratogenic effects of drugs administered during the critical embryogenie period of pregnancy drastically limit their use. Because of this, many pregnant women turn to complementary and alternative therapies including vitamins, herbal products, homeopathic preparation, acupressure, and acupuncture. A recent literature survey reports that the most commonly used botanicals for the treatment of morning sickness are ginger, chamomile, peppermint, and raspberry leaf. Only ginger has been subjected to investigation of its safety and efficacy for nausea and vomiting of pregnancy.

Botanical Treatment Strategies for nausea and vomiting of pregnancy and Hyperemesis Gravidarum

Therapeutic Goal Therapeutic Activity Botanical Name Common Name
Reduce nausea and vomiting Antinauseant 

Antiemetic

Cannabis spp. Marijuana
Mentha piperita Peppermint
Zingiber officinalis Ginger
Relieve stomach cramps Antispasmodic Dioscorea villosa Wild yam
Matricaria recutita Chamomile
Support digestion / appetite Digestive bitters Ballota nigra Black horehound
Taraxacum officinale Dandelion root

 

The botanical approach to treatment of nausea and vomiting of pregnancy and Hyperemesis gravidarum, like conventional therapy, includes supportive, nonpharmacologic, and pharmacologic therapies, the latter in the form of antinauseant / antiemetic and antispasmodic herbs, and the use of gently herbs that support digestion (Table Botanical Treatment Strategies for nausea and vomiting of pregnancy and Hyperemesis Gravidarum). The supportive and nonpharmacologic therapies used with herbal interventions are the same as those used with conventional therapies, and are described under Nonpharmacologic Treatment of nausea and vomiting of pregnancy and Hyperemesis Gravidarum. Nausea and vomiting of pregnancy can be challenging to treat with consistent effectiveness in any individual woman, because it is difficult to find a single remedy that works consistently, especially over a prolonged time period. Typically, women find relief from a specific protocol for a short duration, only to find themselves nauseated by the remedy that helped in the first place. Therefore, it is preferable to have a “repertoire” or options a woman can try, and suggest she rotate these to create some variety and not become resistant to any single approach.

The literature is unclear and contradictory regarding the safety of the herbs used for nausea and vomiting of pregnancy during pregnancy, which is especially concerning as they are used most extensively during the first and early second trimesters when embryonic / fetal development is critical. Historical and anecdotal use suggests a high degree of safety, but as with as substances taken during pregnancy, care should be exercised. Specific safety data are presented with individual herbs.

Ginger

The best studied herb for nausea and vomiting of pregnancy is Zingiber officinalis. A recent systematic literature search by Borrelli et al. identified six double-blind RCTs with a total of 675 participants and a prospective observational cohort study, which met the inclusion criteria for the review. The methodological quality of 4 of 5 of the RCTs was high according to the Jadad scale. The six studies are outlined in Table Clinical Trials Demonstrating Efficacy of Ginger for nausea and vomiting of pregnancy.

Clinical Trials Demonstrating Efficacy of Ginger for nausea and vomiting of pregnancy

Author Study Design Weeks Gestation Dose Control Treatment Duration Main Outcome
Fischer-Rasmussen, 1990 Randomized, double-blind, cross-over <20 250 mg 4x / day Placebo 4 days Based on a 4-point subjective scoring system for severity and relief of nausea and vomiting and weight loss measurement, ginger was better than placebo in alleviating or eliminating nausea and vomiting of pregnancy
Vutyavanich, 2002 Randomized, double-blind <17 250 mg 4x / day Placebo 4 days Based on severity of nausea and vomiting (subjective reporting), number of vomiting episodes; occurrence of side and adverse effects on pregnancy, ginger was more effective than placebo in reducing the severity of nausea and vomiting
Keating, 2002 Randomized, double-blind <12 250 mg 4x / day Placebo 2 weeks Using a 10-point scale to evaluate the duration and severity of nausea and vomiting, ginger was more effective than placebo in reducing nausea
Sripramote, 2003 Randomized, double-blind <17 500 mg 3x / day Vitamin B6 3 days and stopping vomiting Using a visual analog scale to evaluate severity of nausea, number of vomiting episodes, and occurrence of adverse effects ginger was found to significantly reduce nausea score, and fewer vomiting episodes were noted
Willetts, 2003 Randomized, double-blind <20 125 mg 3x / day Placebo 4 days Ginger was observed to be more effective than placebo in reducing nausea and retching. No effects on vomiting symptoms were reported.
Smith, 2004 Randomized, double-blind >8, <16 350 mg 3 / day Vitamin B6 3 weeks Ginger was found to be as effective as vitamin B6 at days 7, 14, 21 in reducing nausea, dry retching, and vomiting compared with baseline.

Four of the six RCTs (n = 246) showed superiority of ginger over placebo; the other two RCTs (n = 429) indicated that ginger was as effective as the reference drug (vitamin B6) in relieving the severity of nausea and vomiting episodes, including one study by Fischer-Rasmussen et al. that demonstrated efficacy and was superior to placebo for the treatment of hyperemesis gravidarum. The observational study and RCTs showed the absence of significant side effects or adverse effects on pregnancy outcomes. There were no spontaneous or case reports of adverse events during ginger treatment in pregnancy. The evidence, both scientific and traditional, is that ginger is safe and effective for some women with mild or moderate nausea and vomiting of pregnancy. It can be taken in the form of ginger ale, ginger tea sipped in small doses (to avoid nausea that may from drinking large amounts of any fluid), ginger capsules, or even candied ginger or spiced ginger cookies. It is generally recommended that women take on up to 1 g daily, as this is the largest amount that has been studied in clinical trials and been demonstrated as safe. Ginger ale must have real ginger in it, not just ginger flavoring, to be effective. The use of ginger is affordable and many women find this an acceptable approach, preferring to try this before resorting to conventional medications. The various routes of administration allow women to change how they are taking it regularly, which can help them avoid becoming sensitized to and nauseated from the ginger flavor. Occasionally, some women find the flavor unpleasant; adding peppermint leaf to the tea may improve the flavor for these women. Capsules allow women to avoid the smell and taste; however, some may find that eructation is unpleasant. As with all nausea and vomiting of pregnancy remedies, there will be a great deal of individual variety determining what is palatable and tolerable.

Peppermint

Peppermint has a long history of use as a digestive aid, for improving digestion after meals, and calming nausea, flatulence, and abdominal spasms. The role of peppermint in the treatment of nausea and vomiting of pregnancy has not been investigated; however, some benefit has been shown for the treatment of postoperative nausea, and also for the treatment of esophageal dysmotility, a physiologic finding that is also postulated as part of the etiology of nausea and vomiting of pregnancy. Anecdotally, peppermint reportedly has a calmative effect on the stomach, in addition to reducing nausea, in women with nausea and vomiting of pregnancy. It is taken as a tea in small sips (often combined with ginger for a pleasant-tasting tea), in the form of peppermint-flavored candies, or peppermint oil indirectly inhaled as aromatherapy. For the latter, many pregnant women have found it effective to douse a small piece of cotton wool with peppermint oil, and place this in a small glass vial that can be carried around in the pocket, opened and whiffed as needed, for example, during car travel. It is considered a safe and gentle remedy; however, peppermint herb is rich in volatile oils that can cross the placenta; thus, care should be taken to use only if necessary and in small amounts as a tea only, and not as a tincture or essential oil for ingestion. Neither the Botanical Safety Handbook, nor the German Commission E contradict the use of peppermint during pregnancy.

Black Horehound

British trained herbalists commonly use black horehound in the treatment of motion sickness and nausea and vomiting of pregnancy and with reports of great effects. The safety of this herb during pregnancy has not been evaluated. It is typically taken in small does (1 to 2 mL tincture three times / day), in combination with ginger, cha-momile, or peppermint. It may also be added to a small amount of ginger ale or carbonated water (see dandelion root).

Wild Yam

Wild yam has been used in herbal medicine as an anti-spasmodic for not only the uterus and bladder, but for the stomach and intestines as well. The Eclectic physicians reported its use for the treatment of nausea and vomiting of pregnancy, a use which has found its way into contemporary midwifery-botanical practice.ls,lss,ls Steroidal saponins in the plant may exert estrogenic effects by binding with endogenous estrogen receptors in the hypothalamus; however, this has only been demonstrated in vitro. There is no evidence to contraindicate the use of this herb during pregnancy, nor research on its safety or efficacy during pregnancy. There are no reports in the literature of wild yam having emmenagogic effects. It is typically taken in repeated doses of small amounts (e.g., 20 to 30 drops) in tincture form, sometimes combined dandelion root tincture (see the following) or added to ginger tea, when other remedies alone have failed.

Dandelion Root

Dandelion root is traditionally used as a gentle digestive bitter to improve digestion, increase bile flow choleretic, and relieve nausea and vomiting and improve appetite. The bitter constituents in dandelion increase bile flow, and act as an appetite stimulant. There are no reports in the literature of dandelion being either safe or contraindicated during pregnancy. Herbalist-midwives may recommend it taken alone in small doses (1 to 15 drops) as a tincture in water, or this same dose added to half a glass of ginger ale or lemon-flavored carbonated water. It has a mildly bitter taste, but dilute, is not typically offensive to pregnant women.

Cannabis

Cannabis (marijuana) has at least a 4000-year history of use as a medicinal plant, including extensive use for the treatment of gynecologic and obstetric conditions in many cultures throughout the world. It was first described in Western medical literature by a physician in Ohio who used an extract of Cannabis indica to successfully remedy a near fatal case of hyperemesis gravidarum. Cannabinoids, delivered in the form of pharmaceutical preparations (e.g., nabilone and delta(9)-tetrahydrocannabinol) or directly smoked by the patient, are effective in reducing chemotherapy-induced nausea, vomiting, and anorexia, and may significantly improve appetite and ability to eat and drink. It is used extensively by patients undergoing treatment for cancer and HIV, and may provide novel therapies for other GI disorders, including gastric ulcers, irritable bowel syndrome, Crohn’s disease, secretory diarrhea, paralytic ileus, and gastroesophageal reflux disease. The 5-HT3-receptor antagonists, including cannabinoids, offer enhanced control of emesis while causing few side effects. Marijuana use may improve treatment adherence in patients undergoing treatments with protocol that have a high rate of side effects, such as HIV and cancer chemotherapy. Clinical trials that have looked at the efficacy of cannabis as an antiemetic have found it better than conventional antiemetics. Not only does cannabis reduce nausea and vomiting, but it has a significant effect on improving appetite and caloric intake. Patients with multiple sclerosis (MS) symptoms report reductions in nausea, and improved ability to eat and drink, among improvement in other MS-related symptoms. In additional to its effects on central nervous system receptors, new research suggests the role of cannabinoids in the treatment of esophageal dysfunction, as one of its mechanisms of action. There are strong indications that cannabis is better tolerated than THC alone, because cannabis contains several additional cannabinoids, like cannabidiol (CBD), which antagonize the psychotropic actions of THC, but do not inhibit the appetite-stimulating effect.

Cannabis is reported to be the most widely used recreational drug in pregnancy, with use during pregnancy in developed nations estimated to be approximately 10% to 20%. Not uncommonly, it is self-prescribed for nausea and vomiting of pregnancy. A recent (2003-2004) survey of 84 female users of medicinal cannabis, recruited through two compassion societies in British Columbia, Canada, found that of the 79 respondents who had experienced pregnancy, 51 (65%) reported using cannabis during their pregnancies. Although 59 (77%) of the respondents who had been pregnant had experienced nausea and / or vomiting of pregnancy, 40 (68%) had used cannabis to treat the condition, and of these respondents, 37 (over 92%) rated cannabis as “extremely effective” or “effective.” It is widely used by Rastafarian women in Jamaica and elsewhere to treat nausea and vomiting of pregnancy, as well as other complaints, for example, labor pain. Because of its status as an illegal drug, as well as the general ethical issues that arise regarding conducting clinical studies during pregnancy, no formal clinical trials that examine the efficacy of this herb for use during pregnancy have been conducted. Because of its widespread use, its safety during pregnancy has been the subject of significant investigation; however, according to Westfall et al., it is important to be cognizant when evaluating marijuana and pregnancy safety data, that data derived from recreational use may not be equivalent to that which might be derived from therapeutic use, in terms of adverse effects. The influence of cannabis use during human pregnancy, and indeed, the medical use of marijuana generally, have been fraught with contradictions and controversies. A recent Medline database search by Karila et al. conducted for articles indexed from 1970 to 2005 using the terms cannabis / marijuana, pregnancy, fetal development, newborn, prenatal exposure, neurobehavioral deficits, cognitive deficits, executive functions, cannabinoids, and reproduction suggested that cannabis use during pregnancy is related to diverse neurobehavioral and cognitive outcomes, including symptoms of inattention, impulsivity, deficits in learning and memory, and a deficiency in aspects of executive functions. However, composite learning scores in these studies were not lower than controls, and adverse effects on learning were not significant when home factors were included. It is therefore difficult to ascribe direct effects on learning and behavior to maternal cannabis consumption during pregnancy. A report by Park et al. states that few studies have been conclusive regarding the effects of cannabis use during pregnancy. Cannabis use has been correlated with low birth weight, prematurity, intrauterine growth retardation, presence of congenital abnormalities, perinatal death, and delayed time to commencement of respiration. However, increased evidence of increased mecon-ium staining was observed in newborns of heavy marijuana users who were from low-risk pregnancy and socioeconomic categories. Studies evaluating the use of cannabis during pregnancy have been confounded by the failure to separate the effects of alcohol versus marijuana on the newborn. A large survey (n= 12060) of British women showed no significant different in growth of the babies among women who did vs. did not use cannabis during pregnancy, based on self-report. Another large survey (n= 12885) of women in Copenhagen, which controlled for both alcohol and tobacco use, showed similar findings. A multisite study in the United States (n=7470 women) showed no correlation between maternal cannabis intake and adverse pregnancy outcome including premature birth, low birth weight, or placental abruption. A study of Jamaican births (w = 9919) showed no correlation between maternal cannabis use and perinatal morbidity or mortality. Side effects of use reported in the HIV community and general population include more side effects, feeling high, sedation, euphoria, dizziness, dysphoria or depression, hallucinations, paranoia, and arterial hypotension. Chronic cannabis use has been reported to affect memory in patients using it to treat HIV chemotherapy-induced symptoms, and a study found that acutely, cannabis can impair driving response. Clearly, cannabis has effects on brain activity, cognition, perception, and function. Herbalists consider cannabis to be a reliable antiemetic, antinauseant, antianorexic, and analgesic. It is also considered to have mild oxytocic effects.

What remains unknown is the effects of small amounts of marijuana intake during pregnancy for the specific treatment of nausea and vomiting of pregnancy, anorexia, and weight loss, both independently and as compared with no treatment or the use of conventional antiemetics. As it can be expected that some population of pregnant women entering the clinic with nausea and vomiting of pregnancy will be self-medicating with cannabis, it is important to elicit honest communication from the patient using a nonjudgmen-tal approach, in order to ascertain how much cannabis the woman is using and what effects she feels it is having. Drug adulterants such as ketamine and others are common in street product, and can pose serious and dangerous consequences to the mother and fetus.